management of intra operative - ucsf cme– definitive – end‐organ support agenda •...

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Management of Intra‐operative Sepsis

David Shimabukuro, MDCMMedical Director, 13 ICU

Physician Lead, UCSF Sepsis Bundle Compliance and Mortality Reduction

Intra‐operative Management of Sepsis

David Shimabukuro, MDCMMedical Director, 13 ICU

Physician Lead, UCSF Sepsis Bundle Compliance and Mortality Reduction

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Agenda

• Epidemiology

• Definitions

• Treatment

– Definitive

– End‐organ support

Agenda

• Epidemiology

• Definitions

• Treatment

– Definitive

– End‐organ support

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Epidemiology

• Observational cohort study

• 847 non-federal hospitals in seven states

• 192,980 patients

• Patients with documented infection and acute

organ dysfunction by ICD-9

Angus et al, Crit Care Med, 2001

Epidemiology

• 750,000 cases per year

• 3 cases per 1000 population

• 51% received intensive care

• 17% received mechanical ventilation

• Overall mortality 28%, increasing with age

• $ 22,100 per case

• $ 16.7 billion nationally

• Estimated 1.5% increase annuallyAngus et al, Crit Care Med, 2001

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Compared to other major diseases

†National Center for Health Statistics, 2001. §American Cancer Society, 2001. *American Heart Association. 2000. ‡Angus DC et al. Crit Care Med. 2001 .

0

50

100

150

200

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300

AIDS* Colon Breast

Cancer§CHF† Severe

Sepsis‡

Cas

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Incidence of Severe Sepsis

Date of download: 8/27/2012

Copyright © American College of Chest Physicians. All rights reserved.

From: Nationwide Trends of Severe Sepsis in the 21st Century (2000-2007)National Trends of Severe Sepsis in 21st Century

CHEST. 2011;140(5):1223-1231. doi:10.1378/chest.11-0352

Frequency of admission and mortality rates due to severe sepsis, 2000-2007. Bars represent SEM.

Figure Legend:

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Death rate over time

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50

100

150

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2000 2002 2004 2006 2008 2010

Heart Disease

Malignant Neoplasms

Cerebrovascular Disease

Septicemia

National Vital Statistics Reports, vol 6, no 4, May 08, 2013

Source of Sepsis

19%

13%5%

36%

20% 7%

Lung

Blood Skin

Abdomen

Urinary tractOther

Bochud et al, Int Care Med 2001

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Agenda

• Epidemiology

• Definitions

• Treatment

– Definitive

– End‐organ support

What is Sepsis??

• A variable condition that affects each of us differently and is initiated by a known or suspected infectious insult.

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Sepsis Definitions

• SIRS

• Sepsis

• Severe Sepsis

• Septic Shock

Septic Shock

SEVERE SEPSIS plushypotension (Systolicblood pressure < 90 orMean Arterial Blood Pressure < 65) OR Lactate > 4

Severe Sepsis

SEPSIS plus evidenceof at least one alteration in organ perfusion

Sepsis

SIRS plus confirmed or suspected infection

Sepsis: ACCP/SCCM Definitions

SIRS

T > 38.3 C or < 36 CHR > 90 beats/minTachypneaWBC > 12K or < 4K

SIRS

T > 38.3 C or < 36 CHR > 90 beats/minTachypneaWBC > 12K or < 4K

SIRS

T > 38.3 C or < 36 CHR > 90 beats/minTachypneaWBC > 12K or < 4K

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Severe Sepsis Definition

Crit Care Med  February 2013 Volume 41 Number 2 pp. 580‐637

San Francisco Definition

• Sepsis is defined as a life‐threatening organ dysfunction due to a dysregulated host response to infection.

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Inflammatory ResponseExcessive systemic Inflammatory response Immunodepression

Appropriate inflammatoryresponse

“Storm”

“Wake”

Early mortality Late mortality

Coagulation Regulation

• Normal response to injury is a contained explosion of thrombin generation

• TNF and IL‐1 activate coagulation pathway

• Endothelium acts like a fire extinguisher– Antithrombin

– Thrombomodulin/Protein C

– Act to neutralize thrombin and prevent conversion of fibrinogen to fibrin

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Loss of Homeostasis in Sepsis

homeostasis

•Proinflammatory mediators•Endothelial injury•Tissue factor expression•Thrombin production

•Increased PAI-1•Reduced Protein C

Pathophysiology of Sepsis

EndothelialInjury

CoagulationFibrinolysis

Inflammation

Organ Failure

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Agenda

• Epidemiology

• Definitions

• Treatment

– Definitive

– End‐organ support

Definitive Treatment

• Antibiotics

• Source Control

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Management of Severe Sepsis and Septic Shock

Crit Care Med  February 2013 Volume 41 Number 2 pp. 580‐637

Management of Severe Sepsis and Septic Shock

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Management of Severe Sepsis and Septic Shock

• Antibiotics should be administered within 60 minutes from the time of recognition.

Crit Care Med 2006 Vol. 34, No. 6

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End‐organ support (by improving tissue perfusion)…

Management of Severe Sepsis and Septic Shock

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Management of Severe Sepsis and Septic Shock

• Normalization of lactate as a resuscitation goal is suggested

– Use of rate of lactate clearance is mentioned, but not endorsed as a sole target

Management of Severe Sepsis and Septic Shock

• Fluid Therapy

– Crystalloids are first choice for the overwhelming majority of patients

– Albumin can be used to reduce volume from crystalloids

– Hydroxyethyl starches should not be used

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Management of Severe Sepsis and Septic Shock

• Fluid Therapy

– WATCH OUT!!!!!

– Too much fluid is bad and not enough is bad…

Management of Severe Sepsis and Septic Shock

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Management of Severe Sepsis and Septic Shock

• Corticosteroids

– For refractory hypotension despite fluids and vasopressors/inotropes

– Do not perform ACTH stimulation test

• Glucose

– Target level to less than 180 mg/dL

Things more specific to the OR…

• Avoid etomidate

– Inhibits adrenal mitochondrial hydroxylase activity

– Decreases steroidogenesis

• Pre‐treatment with alpha/beta‐agonist before induction

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Things more specific to the OR…

• NMDA

– Increase in initial dose

• Increase in volume of distribution

• Increase in alpha‐1 acid glycoprotein

– Prolonged recovery from renal and liver dysfunction

Things more specific to the OR…

• Lung Injury

– All patients at risk

– Low‐tidal volume ( 6cc/kg IBW)

– Plateau pressure < 30 cm H20

– Permissive hypercapnia

– Minimize FIO2

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Things more specific to the OR…

• Glucose homeostasis

– Hyperglycemia very common, but can have hypoglycemia

• Kidney and Liver dysfunction

• Coagulation abnormalities

– Disseminated Intravascular Coagulation (DIC)

Things more specific to the OR…

• METABOLIC ACIDOSIS

– Treat the underlying cause

– Sodium Bicarbonate

• Better tolerated as continuous infusion rather than intermittent bolus dosing

• Acidemia is better for oxygen unloading from hemoglobin (left‐shift of HGB‐Oxygen dissociation curve)

• Can worsen intra‐cellular acidosis leading to worsening of organ dysunction

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Conclusions

• We will all have patients that will develop severe sepsis while in the OR or will already have severe sepsis/septic shock and is in the need for source control

• Definitive treatment for severe sepsis/septic shock involves rapid appropriate antibiotic administration and source control

Conclusions

• Etomidate should not be used as a first‐line agent for induction

• Drugs may take longer to work and last longer than expected

• Acidemia is not necessarily bad

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QUESTIONS??